Angioedema after Administration of tPA for Ischemic Stroke: Case Report

Persistent, severe post-thrombolysis angioedema: Simple management of a difficult problem

“…By its intended thrombolytic mechanism, t-PA generates the protease plasmin, which degrades fibrin thereby degrading fibrin clots. However in addition to this action, plasmin also cleaves bradykinin from high molecular weight kininogen [8]. Bradykinin increases vascular permeability producing angioedema.…”

“…The proposed reasons for this include better detection of angioedema by neurologists who focus on cranial nerve examination as well as the vasomotor changes that accompany the autonomic dysregulation seen in stroke patients [7]. A unique aspect of postthrombolysis angioedema is the almost characteristic asymmetry of the angioedema, whereby swelling is noted on the side contralateral to the ischemic hemisphere [8]. Whilst the reasons for this are not entirely clear, it is proposed that infarction of the contralateral insular cortex impairs autonomic function resulting in vasomotor changes on the hemiparetic side, as seen in our case [3,9].…”

“…The primary mechanism of t-PA associated orolingual angioedema is through the generation of plasma kinins [3,8]. By its intended thrombolytic mechanism, t-PA generates the protease plasmin, which degrades fibrin thereby degrading fibrin clots.…”

Audit report and systematic review of orolingual angioedema in post-acute stroke thrombolysis

“…2). When the two studies by Hill (2000 and2003), 21,22 likely included in a subsequent multicentre study in 2005, 20 were excluded from the metaanalysis, the overall estimate per 1000 patients was 12 (95% confidence intervals: [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22], again with evidence of heterogeneity (P , 0.0001). Two recently published large studies (Guillain and Zinkstok) had much lower occurrence rate of PIROLA than all other included studies.…”

“…Of the 1215 citations identified through the searches, 70 abstracts were selected for in-depth evaluation and 67 full texts were reviewed and 27 were included in the final selection ( Table 2). Sixteen of these studies [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] were case reports or case series, while the eleven others were audit reports or (Table 2). Twenty per cent of PIROLA patients required airways assistance in the form of either orotracheal intubation or tracheotomy, and no PIROLA-related death was recorded.…”